Diagnosing the Disparity
It can be tempting to jump right into “doing something” about disparities. But to maximize your efforts it’s important to understand exactly what is going on. Why do disparities exist at your organization? Which causes of disparities are realistic to tackle right now?
The answers to these questions will inform how you design your equity program, which we'll explore in Roadmap Step 4, Designing the Activity. Your assessment will help ensure that the activity is relevant to your priority population and that there’s uptake among staff and patients.
Finding Answers has developed a method for understanding the root causes of disparities and identifying priority areas for change. We take a standard quality improvement tool – the Root Cause Analysis – and apply an “equity lens” to help you focus on disparities in care. Then we use a Priority Matrix to assess which causes are most feasible and important to address.
In this step of the Road Map, we’ll walk you through this process. We’ll define what we mean by an equity lens and discuss how to apply it to a Root Cause Analysis. We’ll also share strategies for deciding which root causes to tackle.
What is an equity lens?
What do we mean by applying an equity lens? We mean that we are looking for issues that contribute to the disparity—the difference in quality of care and outcomes between different populations.
To apply an equity lens, consider the issues that are relevant to your priority population and might contribute to this difference in care. A good way to do this is to ask questions related to the needs of your priority population. For example:
- What is the patient’s comfort level discussing personal health issues with a provider or peers?
- Does the provider have medical fluency in languages other than English?
- Do members of the immediate care team understand patients’ day-to-day life outside of the clinic and are they able to make appropriate, affordable referrals to encourage healthy living?
- Does the organization’s schedule accommodate evening or weekend hours?
- Is the community safe for outdoor recreation?
- What are the policies around reimbursement for certain health services?
These questions and others can be relevant for minority patients because they acknowledge and address issues around communication, culture, and context. Note that they can impact all levels of the health care system, including the patient, the provider, the immediate care team, the organization, the community, and the political climate.
What is a Root Cause Analysis?
A Root Cause Analysis (RCA) is often used in quality improvement to understand why a specific undesirable incident occurred. For example, why did a patient fall at the hospital, or why are post-surgery infection rates increasing? An RCA helps identify the underlying causes of these incidents.
For the purposes of the Road Map, Finding Answers uses the term more broadly to assess why a racial or ethnic disparity exists among a particular patient population. For example, in your organization, why do Latino patients have a higher rate of uncontrolled hypertension than white patients?
Different tools exist to conduct an RCA. These include: process-mapping, the “5-Why’s,”and a Cause-and-Effect Diagram (AKA Fishbone Diagram), among others).
For example, the Fishbone Diagram provides a framework that helps us identify and organize the potential causes of a problem. It allows us to drill down to the specific drivers of the issue.
Here is an example of a Fishbone Diagram that answers the question: Why am I not getting enough sleep?
What does it mean to apply an equity lens to a Root Cause Analysis?
When you apply an equity lens to a Root Cause Analysis, you focus on issues that contribute to a difference in care.
While you shouldn’t ignore the issues that affect quality of care for everyone, using an equity lens acknowledges and builds on those issues to learn how some patients may be affected differently. Considering both general quality-improvement issues and equity-specific causes help us to improve quality while also reducing disparities. Here’s an example to demonstrate what we mean:
Imagine that the race/ethnicity/language data from your practice shows that your Latino patients consistently have higher blood pressure than your White patients. You are considering the causes of this disparity.
First, you may discover that your patients are not taking their blood pressure medication. Why might that be?
One explanation is that patients experience undesirable side effects that prompt them to skip doses, which is a potential issue that may be important to address.
However, it is not per se a cause that explains the difference in blood pressure between Whites and Latinos—so we need to look at other issues in addition to this one. If you designed an intervention to address this issue alone, it might improve overall rates of medication adherence without specifically addressing the disparity between White and Latino patients. In fact, it may inadvertently increase the disparity between populations, as demonstrated in our example from Roadmap Step 1.
So, while you will have improved care—which is great!—you will not have improved equity. Even though you are looking at an issue related to a documented disparity, this kind of reasoning does not apply an equity lens.
Now, what would it look like to apply an equity lens?
Your data might tell you that your Latino patients have more comorbidities than other patients, including depression and obesity. They are more likely than other patients to take multiple medications for multiple conditions. Is it possible that they are experiencing drug interactions that cause undesirable side effects and prompt non-adherence?
Looking for underlying causes is the kind of reasoning you use when applying an equity lens to your Root Cause Analysis: ask yourself which issues are relevant to my priority population and might contribute to the disparity?
Do your Latino patients, on average, have lower literacy or lower health literacy than other patients? There may be confusion about what medicine to take, how much to take, and when to take it. Is their medication covered by Medicare or Medicaid? If not, your low-income patients might not be filling their prescriptions. If some of your Latino patients are low-income, that may be a contributing factor.
Finding Answers has created a document that lists many potential root causes of disparities. While not exhaustive, Key Considerations provides a starting point for considering the various circumstances that can affect quality of care differently for different populations.
This kind of reasoning helps us focus our equity lens as we examine documented disparities. It allows us to identify the specific needs of our minority patients that are not being met.
How to conduct a Root Cause Analysis with an equity lens
There are many potential causes of any disparity, so it’s important to gather diverse perspectives and input as you conduct your Root Cause Analysis (RCA) and apply an equity lens. You’ll put together a team that will meet over the course of several weeks or months to complete the exercise. This will involve gathering feedback from stakeholders throughout the organization, utilizing tools such as the Fishbone Diagram to organize potential causes, and determining which root causes to prioritize and address.
Who will be involved?
Build a core team that includes multiple perspectives. This might include:
- Patient representatives or CAB members: Patients have answers! Patients experience care differently than clinic staff and providers, so getting their input is crucial. Staff may be too close to the problem or unwilling to recognize their role in perpetuating disparities. Patients can offer honest feedback about why those disparities exist. Whenever possible, conduct focus groups, surveys, or interviews with patients and involve CAB members in the root cause analysis process. Community groups that serve the priority population are another valuable resource.
- An equity champion: As we discussed in Step 2 of the Roadmap, an equity champion is someone who. Since this person is especially tuned in to issues about equity at your organization, she or he can provide insight that others may miss.
- A Quality Improvement specialist: It can be useful to integrate the RCA team with your organization’s existing quality improvement (QI) team. QI experts often have experience conducting RCA’s and may offer helpful tips on doing them effectively and efficiently.
- A leadership figure: It’s important to involve leadership, as they often have the influence to affect change once root causes are identified. They may also havae insight into potential policy-level causes of a disparity.
- A frontline provider and/or staff member: Frontline providers and staff, including administrative and support staff will be familiar with day-to-day details. Including their perspective is key to developing an accurate analysis.
How will they be involved?
Ideally, your RCA team will gather information from different stakeholders, compile everyone’s input, and report back to see if any key information is missing.
It’s important to remember that the issues identified in your RCA can be challenging to discuss because they are sensitive. You may be asking some tough questions about race. Some useful tips for facilitating these discussions are to:
- Ask open-ended questions. If your questions are too specific, you may limit the responses of your participants and you are likely to miss important factors.
- Give participants the opportunity to consider the topic outside of meeting with your team. They may have more time to develop ideas and discuss them with their peers.
- Provide opportunities for anonymous feedback, or to provide feedback outside of the group.
Further resources for discussing sensitive topics are available on the Resources page.
The important final step of any RCA is to make sure that the results are disseminated throughout the organization.
Think carefully as a team about the best way to share this information and who should be the person(s) to share it. Remember that it’s always a delicate matter to call out problems and identify areas for improvement. Strategize so that your message is heard.
The Priority Matrix
Where do I start?
Keep in mind that sometimes it’s best to tackle the “low-hanging fruit”—one of the simpler and more feasible issues to address. Showing a “quick win” – even if it’s a small one - can help build momentum around disparities reduction and keep staff motivated in the long run. Quick wins can also help garner support from organizational leadership for current and future equity activities.
At the same time, it’s important to manage expectations. Be clear with staff and leadership that you are going for the easy stuff first, to test the waters and build momentum.
By the time you’ve completed your RCA, you will have identified many root causes of the targeted disparity. How will you choose which ones to tackle? A priority matrix is a tool to help you identify which causes are most important and most feasible to address in your health care setting.
It’s helpful to start with the most specific root causes identified through your Root Cause Analysis (RCA), because these are often the key drivers of the disparity. In the Fishbone Diagram, for example, these would be the smallest bones in your diagram.
For each cause, ask yourself the following question and place the answer in the appropriate box:
- How feasible is it to tackle this issue?
- How important is it to tackle this issue?
Because you’ve already gathered a well-informed and diverse team to complete your RCA, you can use the same team to respond to these priority questions and come to consensus on the answers.
Each organization will take a different approach to deciding what is “feasible” and what is “important.” Your decision may be informed by quantitative date - for example, from a recent needs assessment - or qualitative data provided by experts on your RCA team. Either way, there are a handful of common considerations, such as staff time, cost, and the reach of the intervention. Here are some questions to ask yourself as you complete the matrix:
- Reach (penetration) – is a large portion of your priority population affected by this issue?
- Urgency – is prompt/immediate action required? At times, this may be a matter of going with “gut feeling,” if your team has consensus that a particular issue is really important to address right away.
- Cost – how much funding is needed to address this root cause? Does the issue currently cost the organization a lot of money and staff time? Will an intervention help many people, including both patients and staff?
- Effort – how labor- and time-intensive will it be to address the issue? Do you have the staff capacity?
- Readiness and political will – is there momentum and willingness to address this issue? Consider organization leadership, staff, patients, and the community you serve.
- Existing resources and infrastructure – are resources already in place that can help in addressing this issue? It’s important to consider competing demands from other quality improvement initiatives at the organization. Integrating your equity efforts with other programs can improve your chances of success. The process of designing programs that can be integrated with existing work is discussed in detail in Step 4 of the Road Map, Designing the Activity.